- Pictorial Review
- Open Access
Pelvi-perineal flap reconstruction: normal imaging appearances and post-operative complications on cross-sectional imaging
© European Society of Radiology 2011
- Received: 26 September 2010
- Accepted: 14 January 2011
- Published: 2 February 2011
Radical pelvic surgery is often required in patients with advanced, persistent or recurrent gynaecological and anorectal malignancies. In the last decade, pedicled flap reconstructions have been increasingly used for pelvic floor and neovaginal reconstruction, introducing well-vascularised non-irradiated tissue into the wound cavity and hence reducing wound complications. The aim of this pictorial review is to describe the normal post-operative cross-sectional imaging appearances of the most commonly used pelvi-perineal flap reconstructions and to illustrate the complications that may arise at the flap donor and recipient sites.
- Surgical flaps
- Computed tomography
- Magnetic resonance imaging
- Post-operative complications
- Pelvic exenteration
In recent years, radical pelvic surgery has been increasingly undertaken in patients with locally advanced, persistent or recurrent gynaecological and anorectal malignancies. Surgery is carried out either as a curative or palliative procedure and includes an extended abdominoperineal excision (APE) and possibly an anterior, posterior or total pelvic exenteration (TPE). These radical surgical techniques are associated with high morbidity, with the risk of both local and more generalised complications. A wide cutaneous defect and large dead space within the pelvis increases the risk of post-operative perineal complications that occur in up to 25-60% of patients [1, 2]. Local complications include wound dehiscence, abscess or haematoma formation, fistula or sinus formation, delayed wound healing and, rarely, a perineal hernia. The frequent use of neoadjuvant (chemo-)radiotherapy in order to reduce local recurrence rates also contributes to delayed wound healing, due to ischaemic hypoxia from vessel thrombosis and impaired fibroblast proliferation [3–5]. In an effort to overcome these problems, pedicled flaps (in the form of muscle, myocutaneous or fasciocutaneous flaps) have been increasingly employed. This method introduces well-vascularised non-irradiated tissue into the wound cavity and can be used for pelvic floor and, in the case of female patients, neovaginal reconstruction.
Cross-sectional imaging is a valuable tool in the post-operative evaluation of patients with pelvi-perineal flap reconstruction. Both computed tomography (CT) and magnetic resonance imaging (MRI) assist in the detection of complications related to the flap donor and recipient sites as well as in the recognition of tumour recurrence. With several flap techniques now used, it is essential that the radiologist can recognise normal post-operative imaging appearances in order to appreciate any complications that may arise. To date, there has been very little literature on the cross-sectional imaging appearances of such patients [6, 7].
The purpose of this paper is twofold: (1) to describe the three most commonly employed surgical techniques used for pelvi-perineal flap reconstruction at our centre—i.e. the vertical rectus abdominis myocutaneous (VRAM) flap, the gracilis flap and the inferior gluteal artery perforator (IGAP) flap—and their normal post-operative appearances on CT and MRI, and (2) to illustrate the post-operative complications related to both the flap donor and recipient sites.
The VRAM flap
A right-sided VRAM flap is usually created, as patients normally require a left-sided colostomy. Rarely, a left-sided VRAM flap is required if there has been previous scarring or a stoma is present on the right hand side. The flap consists of a 5- to 10-cm wide skin paddle designed vertically above the right rectus abdominis muscle. Initially, the anterior rectus sheath fascia is incised and the rectus muscle and the overlying soft tissue is elevated away from the posterior rectus sheath. The pelvic insertion of the muscle is left intact. The superior epigastric vessels are ligated. The deep inferior epigastric artery and vein are isolated to mobilise the pedicle. The flap is then rotated medially and passed into the pelvis to be inserted into the defect created by the resection, with the distal end of the flap lying posteriorly. The skin paddle of the VRAM flap is used to reconstruct the posterior vaginal wall when indicated. Following resection of the primary tumour and formation of the contralateral colostomy, the abdominal wall donor site is closed with a prosthetic mesh.
The VRAM flap was first described by Shukla and Hughes in 1984  and popularised by Tobin et al. in 1988 . The advantages of this flap are that it provides bulkier tissue compared with the other flaps, in order to fill the large dead space. The flap has a wide arc of rotation. The scar for the flap can be incorporated into the laparotomy scar for excision of the primary tumour. The flap prevents small bowel herniation into the pelvis, and thus reduces the risk of adhesions and small bowel fistulas; the latter complication is reduced from 16 to 5% [10, 11]. One disadvantage of the VRAM flap is that it may result in an excessive amount of tissue within the perineal area that cannot be easily shaped.
The gracilis myocutaneous flap was first described for perineal and neo-vaginal reconstruction by McCraw et al. in 1976 . Its use may be limited due to an inferiorly sited dominant vascular pedicle, with a distal vascular origin resulting in a restricted arc of rotation. Donor site scars are cosmetically conspicuous.
At our centre, the gracilis myocutaneous flap is used in patients who require a double stoma following total pelvic exenteration. A bilateral gracilis flap harvest is performed when a total vaginectomy has been carried out and a neovaginal reconstruction is required.
This is a fasciocutaneous flap based on the inferior gluteal artery perforating vessels. The dimensions of the flap are determined by the surface area to be covered. The flap is elevated from the underlying gluteus muscle, with the inferior gluteal and sciatic nerves lying deep to the plane of dissection. The inferior gluteal artery perforator is identified and dissected throughout its length, allowing the flap enough freedom to be advanced into the defect. Bilateral flaps are raised in nearly all of our patients having this form of reconstruction. One flap is placed deep into the pelvis to control the dead space and the second is then brought across the midline to cover the perineal defect.
The IGAP fasciocutaneous flap is a modification of the musculocutaneous gluteal flap, originally described in 1978 by Shaw and Futrell for the closure of perineal sinuses . Assessment of the inferior gluteal artery perforators prior to surgery has been described using CT angiography and Doppler ultrasound . The use of the gluteus maximus muscle is avoided—this is advantageous as it is important for gait and is thus best preserved .
Perineal flap reconstructions are presently performed in tertiary referral centres with a colorectal surgeon performing the APE and/or pelvic exenteration and a plastic surgeon carrying out the flap procedure. Cross-sectional imaging has proved useful in the follow-up of such patients, and allows for the detection of early and late post operative complications related to both flap donor and recipient sites. As CT is more widely available and is quicker to perform, most follow-up imaging for these patients is with this modality. However, MRI (with its improved contrast resolution) is a useful adjunct, especially in the assessment of possible pelvic recurrence. The reporting radiologist needs to have an awareness of the normal post-operative imaging appearances of perineal flap reconstructions in order to appreciate the development of early and late complications. With the increasing use of neoadjuvant chemoradiotherapy, primary flap reconstructions are likely to be increasingly adopted in preference to primary closure in patients requiring radical pelvic surgery. It is hoped that this review has provided the reader with a greater insight into the cross-sectional imaging appearances and potential complications of the most common types of perineal flap reconstruction presently used for this purpose.
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